Assessing the health and wellbeing needs of children entering out of home care – necessary and sufficient?

1. Assessing the health and wellbeing needs of children entering out of home care – necessary and sufficient? Professor Graham Vimpani Clinical Chair, Kaleidoscope Children’s Health Network Head of Discipline of Paediatrics and Child Health, University of Newcastle

2. What’s all the fuss about? “Is it worth the effort and expense that would be needed to improve health needs assessment and health service access for children and young people living in out-of-home care, especially when most kids in foster care seem healthy enough on a day to day basis, and can just be taken to a doctor if they feel sick?”

3. Overview • The case for comprehensive health assessments on entering care • What is happening in Australia now? • Does it make a difference to health and wellbeing outcomes? • Is it sufficient? • What about the carers’ needs? • Effective intervention has lifelong benefits • The role of epigenetics

4. Why children enter OOHC

5. What is the health status of children entering care? • “The majority of children in care are in good physical health and display improvements in psychological functioning over time” (Osborn & Bromfield, AIFS 2007) • Mental health problem 18%; disability 20%; intellectual disability 14% (Vic govt audit)

6. What is the health status of children entering care? South Australian study • 61% (N=326 aged 6-17 yrs) in clinical range for behaviour problems (Sawyer et al, 2007) • 54% needed clinical help but only 24% got it • Proportion with clinical scores on CBCL externalising scale 6-7 times higher than general community NSW Study • 53% girls and 57% boys (N=347 aged 4-9 yrs) had at least one scale of CBCL in clinical range (Tarren Sweeney & Hazell, 2006) • “The only non-clinical populations of children likely to have poorer relationship and behavioural functioning … are those in institutional care or late adoptees following residential care” Kari clinic (Aboriginal and Torres Strait Islander SSW) • Language delays or disorder in 63% • Oral health problems in 37%

7. Sydney Children’s Hospital Clinic Results • 94 children • Age range: 3m to 14yrs • 48% (45) were under 5yrs • 43% girls, 57% boys • Time in care ranged from 1 week to 5 years • 45 children were in their first placement

8. Health Problems - 1 • 97% had 1 or more health issues (medical, developmental, emotional and/or behavioural problems) • Immunisations – 53% up to date • Vision – 18% (16/87) failed screen and referred • 8 Squint • 7 Poor Visual Acuity • 1 Floater 12 pre-existing eye conditions

9. Health Problems - 2 • Development • 69% of under 5s failed screen • 2 autistic behaviours • Speech • 51% of under 5s speech delay • Growth • Failure to thrive - 2 • Small stature – 7 • Overweight - 3

10. Health Problems - 3 • Infections - 14 • Respiratory – URTI, ear • Skin –impetigo, infected eczema, warts, fungal • Skin - 17 • Eczema • Scars • Nappy rash • Impetigo • ?Psoriasis

11. Health Problems -6 • Behavioural and Emotional health • Most significant issue in 54% • Significant mental health issues - 7 • 2 boys depressed • 1 boy with suicidal thoughts • 3 children with significant grief and loss issues requiring counselling • 3 children with symptoms of Post Traumatic Stress Disorder • 1 boy with gender identity issues

12. Implications of SCH study • More than 50% - perhaps 70% - of children and young people will require a secondary level assessment because of developmental and behavioural problems • A smaller proportion may require further assessment because of physical conditions

13. The case for comprehensive assessments • DoCS – Health MOU on Children in OOHC (NSW) (2006) • Royal Australian College of Physicians policy (2006) • Royal Australian and New Zealand College of Psychiatrists (Faculty of Child and Adolescent Psychiatry) (2008) • Wood Special Commission of Inquiry (NSW) (2008) • Keep them Safe (NSW) (2009) • Development of Draft National Standards for children in Out of Home care (FaHCSIA – 2010) • NSW Standards for Statutory Out of Home care (updated 2010)

14. DoCS – Health MOU (NSW, 2006) • Identifying referral points in each Area Health Service for community health, drug and alcohol services, and mental health services • Specialist medical, psychiatric and other health assessment services • Specialised medical and mental health services, including secure in-patient psychiatric acute care appropriate for children and young persons • Specialist sexual offender services for children and young persons who sexually offend.

15. DoCS (NSW) procedures prior to Keep them Safe • All children and young persons should undergo a health, developmental and mental health/behavioural assessment within 60 days of entering care. • The child/young person’s case worker is responsible for arranging these assessments which are carried out by a range of medical and allied health professionals • The physical health/medical component of the assessment should include the following: • completion of a medical history profile of the child and family to understand the health conditions of parents or siblings which may impact on the child’s health, welfare and well-being • immunisation register check • physical examination that checks for growth delay (eg careful measure of weight, height and head circumference) and signs of malnutrition • screening for visual and hearing deficits • screening for signs of pathological conditions that need further investigation (e.g. foetal alcohol syndrome, fragile X syndrome, physical abnormalities that may be related to past abuse) • dental health screening

16. DoCS (NSW) procedures prior to Keep them Safe • A developmental assessment component should also be done which covers domains such as general cognitive functioning, language and communication, gross and fine motor functioning and socialisation • The mental health/behaviour assessment may be deferred • It is the responsibility on the caseworker to obtain the child or young person’s personal health record (Blue Book), from the parents

17. RACP proposals • Ensuring that physical, developmental and mental health assessments are performed on all children who enter out-of-home care within 30 days; • Encouraging ongoing monitoring of needs by identified health care co-ordinators; • Ensuring appropriate timely access to therapeutic services; • Developing a transferable health record system; • Improving training and support for foster carers; • Coordinating a health care centred approach between all agencies involved with this group of children, including Community Services and Education; • Encouraging governments to adequately fund the implementation of the suggested recommendations; and, • Collecting aggregated data and ensuring evaluation of programs.

18. Components of comprehensive health care assessment (RACP) 1 • General health assessment including • a health history of the child and family • physical examination • growth assessment • vision, hearing and dental screening • immunisation register check. • The health assessment information must be documented to ensure easy access for medical professionals • Undertaken by paediatrician, GP, nurse practitioner or Aboriginal Health worker

19. Components of comprehensive health care assessment (RACP) 2 • Developmental assessment incorporating standardised screening tools • e.g. Ages and Stages or Brigance, as an adjunct to clinical assessment, • access to formalised assessment. • Local systems must be developed to fast track therapeutic developmental services to children with identified deficits. • Systems need to be established for liaison with Education representatives

20. Components of comprehensive health care assessment (RACP) 3 • Mental health screening using accessible and validated tools • e.g. Strengths and Difficulties Questionnaire, or Achenbach Child Behaviour Checklist (CBCL). • Infants and toddlers must be assessed for attachment disorders (sic) • Local systems must be developed to provide a therapeutic response to identified needs.

21. Development of an individualised health plan - RACP • Based on results of comprehensive assessment and in conjunction with CPS:- • Identifying a health coordinator for each child; • Promoting a follow-up health review to occur within three months of assessment and subsequently at least on an annual basis.

22. Ensuring equitable health care - RACP • Working with CPS, Education, Health to:- • Develop local systems to ensure that this group of children is not disadvantaged in their receipt of health care services compared to their peers; • Promote the use of fast tracking therapeutic services, given the often, small window of opportunity available due to transient care placements; and, • Ensure that such services are provided for all health needs and in particular mental health needs, utilising both public and private therapeutic services as required

23. Data collection - RACP • Governments be encouraged to develop and resource permanent and easily transferable health records which will be accessible to future health providers and available to parents and carers:- • Using electronic health records linked to Community Services files; • Ensuring these are stored in a safe manner while at the same time allowing them to facilitate health communication; • Recording information that includes a patient hand-held record containing past history, relevant family history, health assessment information, treatments and interventions; • Evaluating the health needs of children placed in out-of-home care and aggregating this data to monitor and identify the effective interventions.

24. Improved access to health records of birth parents - RACP • That the College assist Community Services workers to have access to health records of birth parents in a fashion which is consistent with privacy legislation by:- • Developing a proforma to enable these workers to collect a satisfactory health history from parents • engage with parents over consent for health treatment of their child at the point of entry into care; and, • Entering into discussions with Privacy Commissioners, or similar bodies, to explore the availability of this information to Community Service workers.

25. Enhancing communication - RACP • That the College … advocate increasing the level of communication by: • Facilitating effective communication channels between health professionals, Community Services Departments and other key people in the foster child's life e.g. schools, carers and parents; • Establishing specific communication avenues such as community based inter-agency forums for more complex cases; • Listening and responding to foster children’s opinions and ideas as to how their health needs may be best met; and, • Engaging birth parents in their child’s ongoing health planning where possible.

26. The case for comprehensive mental health assessment and intervention (RANZCP) • Every child entering OOHC has a multimodal mental health assessment as part of the admissions to care process • Children with potential psychopathology should have a comprehensive mental health assessment within 30 days • A profile based on a developmental framework of psychopathology that identifies risk and protective factors that contribute to resilience should be documented for each child at this time • All children with intellectual disability entering OOHC should have a comprehensive mental health assessment routinely

27. The case for comprehensive mental health assessment and intervention (RANZCP) • Treatment plans that organise and prioritise interventions in the major areas of a child’s life should be developed with emphasis on enhancing strengths through therapy or activities that promote the child’s development. These plans may include medication to improve functioning and reduce symptoms • Children in OOHC with MH problems should be given special attention and priority access to MHS • A cost-effective process for assessing these children that does not rely solely on specialist clinicians needs to be developed

28. What should happen re health in KtS, National and NSW OOHC standards? Keep them Safe (2008-2009) • Proposed principles (Wood) • Children and young persons should be assisted to gain regular access to education, health and other services to meet their changing needs and to enable them to grow and develop • Restoration decisions should not take longer than six months, particularly for younger children • Greater in-depth assessment of children and young persons coming into care through more comprehensive assessment and interventions in the crucial early stages of placements should be part of agency placement and planning processes • Care arrangements for children and young persons should be based on their assessed needs, and the assessed capacity of carers to meet these needs • There should be sufficient health and specialist services including dental, psychological, counselling, speech therapy, mental health and drug and alcohol services available to meet the needs of children and young persons in OOHC

29. What should happen re health in KtS, National and NSW OOHC standards? Keep them Safe (2008-2009) • Proposed principles (Wood) • There should a system common to all agencies delivering services to children and young persons in OOHC that collects essential health information and monitors their health and educational outcomes. This should include an accessible, comprehensive medical record or a transferable record for children and young persons in care • Interventions for high needs children and young persons in OOHC should include strong case management, integrated multi-agency work, and highly skilled staff and carers who receive expert supervision, ongoing training and support

30. What should happen re health in KtS, National and NSW OOHC standards? Keep them Safe (2008-2009) • Recommendations (Wood) Recommendation 16.3 • Within 30 days of entering OOHC, all children and young persons should receive a comprehensive multi-disciplinary health and developmental assessment. For children under the age of five years at the time of entering OOHC, that assessment should be repeated at six monthly intervals. For older children and young persons, assessments should be undertaken annually. A mechanism for monitoring, evaluating and reviewing access and achievement of outcomes should be developed by NSW Health and DoCS Govt response: Supported. Role of GPs to be explored Recommendation 16.4 • NSW Health should appoint an OOHC coordinator in each Area Health Service and at The Children’s Hospital at Westmead. Govt response: Supported.

31. What should happen re health in KtS, National and NSW OOHC standards? Keep them Safe (2008-2009) • Recommendations (Wood) Recommendation 16.6 • The NSW Government has a responsibility to ensure that all children and young persons removed from their parents and placed in its care receive adequate health treatment. Thus, there should be sufficient health services including speech therapy, mental health and dental services available to treat, as a matter of priority, children and young persons in OOHC Govt response: Supported Recommendation 16.7 • The introduction of centralised electronic health records should be a priority for NSW Health. Given that this is likely to take some time, an interim strategy should be developed to examine a comprehensive medical record or a transferable record for children and young persons in OOHC, which should be accessible to those who require it in order to promote or ensure the safety, welfare and well-being of the child or young person. Govt response: Supported. Interim - Blue book to have OOHC modules

32. What should happen re health in KtS, National and NSW OOHC standards? Keep them Safe (2008-2009) • Recommendations (Wood) Recommendation 16.11 • A common case management framework for children and young people in OOHC across all OOHC providers, should be developed, following a feasibility study on potential models including the Looking After Children system Govt response: Supported – CS will undertake a feasibility study with a new model to be introduced in 3-5 years Recommendation 16.13 • There should be sufficient numbers of care options for children and young persons with challenging behaviours that include specialised models of therapeutic foster care Govt response: Supported – CS will develop new models of care

33. What should happen re health in KtS, National and NSW OOHC standards? Draft National OOHC standards (2010) • Standard 4. A comprehensive health assessment is provided to children and young people entering care, with ongoing medical needs attended to in an appropriate and timely way, and children and young people have their own written health record which moves with them if they change placements. • Standard 5. Children and young people entering into care receive timely and appropriate therapeutic assessment and support as needed. • Standard 13.Each child and young person has a case plan developed that details their health, education and other needs, which is implemented and reviewed regularly, with the children and young people supported to participate in both the development and updating of their plan.

34. What should happen re health in KtS, National and NSW OOHC standards? NSW standards (2010) • Children and young people’s wellbeing is actively safeguarded • Children and young people are cared for in placements which meet their specific emotional, social and behavioural needs • Children and young people’s health and developmental needs are addressed • Children and young people have initial assessments based on their best interests and are placed according to their identified needs and where relevant, the Aboriginal and Torres Strait Islander Placement Principles • Children and young people have effective behaviour support and management plans where necessary

35. What is happening now (NSW) • 20% of children entering care had a health assessment in 60 days (NSW audit) • Fragmented information systems and poor access to personal and family health information (Wood) • No standard or consistent approach to the collection of data for health screening and assessment (Wood)

36. Activity in Other States • Queensland – Child Health Passport to facilitate placement and annual checks • Victoria – health plans under LAC reviewed every 6 months or annually plus comprehensive intake assessment by GP, paediatrician, mental health professional • WA - children and young persons in OOHC have health and education assessments and plans covering physical, mental and dental care. It is envisaged that the assessment model chosen would review physical growth, progress towards developmental milestones and psychological/emotional development. • SA - Health Standards for Children and Young People under the Guardianship of the Minister. This involves an agreement between the Department of Families and Communities and the Department of Health that Health will provide a comprehensive paediatric assessment upon entry into care

37. Does health assessment make a difference to outcomes?

38. Outcome of SCH health assessments N=100 • 75% received 4 or more recommendations • Medical review 59% • Dental review 52% • Immunisation 44% • Counselling/psychological service 42% • Ear, nose and throat review 42% • In 43 children’s cases, DOCS did not know if one or more recommendations had been implemented

39. Health benefits - SCH • Of the 363 recommendations where a recordable health benefit was applicable, almost 50% were unknown by the caseworker. Examples of health benefits • Of 26 children referred by the clinic for further formal developmental assessment, 12 were found to have significant delays, and relevant educational interventions were in progress • 14 of the 24 children referred for speech assessment had so far been screened, of whom nine were currently receiving speech therapy and making significant language improvements. • There were also examples of children who had undergone major dental work and of children prescribed glasses.

40. Status of SCH recommendations

41. Reasons for Recommendations non-completion Systems Issues • Frequent change of carer • High turnover of caseworker and delays in reassignment of a new caseworker • Poor record keeping • Lack of knowledge regarding service providers • Reluctance to place children on waiting lists until the courts had finalised placement decisions • Caseworkers themselves commented on their own lack of time and resources • for accessing the recommended allied health services • and for tracking the child’s ongoing progress through the health system Lack of services • Counselling • Peer and carer support, • Public dental services • Long waiting lists for allied health services • e.g occupational and speech therapy.

42. Conclusion from SCH study • Benefits of health assessment uncertain • Routine comprehensive health screens clearly improve detection of previously unmet or unrecognised health issues • Screening provides a baseline record of the child’s current health and well-being. • Reasonable to assume that the information and advice provided to carers and caseworkers by the clinic was likely to improve a child’s access to appropriate health services. • Agencies should have systems to ensure better communication and collaboration between the health and community services systems. • Regular medical reviews while a child remains in care and improved inter-agency liaison over implementation of the child’s health plan may improve health outcomes for these children

43. Is health assessment of children entering OOHC sufficient to improve outcomes?

44. Benefits of comprehensive assessments • Are there risks from not having a comprehensive health/mental health assessment? “Children with hidden emotional distress are a particular risk of not being referred or picked up by services. They...have a relationship style that tends to hide their needs from view.” • “Closed book children” • “Too good to be true” (Schofield et al 2000; Crittenden 2009)

45. Benefits of comprehensive assessments “The prevalence, scale and complexity of mental health difficulties experienced by these populations are so great, that delineation between primary and specialist levels of care for these children is blurred. They require universal, comprehensive clinical/psychosocial-developmental assessments following entry into care or adoption. These assessments identify risks and casework-related issues that may contribute to future mental health difficulties, or detract from their development or well-being in other ways. This applies as much to children who enter care with few mental health difficulties. Universal, comprehensive assessment by specialist clinicians following entry into care is thus preferable to mental health screening, because it is designed for prevention of future difficulties as much as detection of present ones. Furthermore, mental health screening alone does not identify critical influences on children’s development that have a bearing on other psychosocial-developmental outcomes (that could be remedied if detected early enough). Beyond initial assessment, there remains a need for a primary care (i.e. population-wide) approach to provision of specialist mental health services, equating to a primary–specialist care nexus.” ( Tarren Sweeney, 2010)

46. What others have said… • Children who have experienced long-term foster care do not benefit from the receipt of outpatient mental health services(Bellamy et al 2010) • “there is little empirical basis for the notion that a higher frequency of services necessarily translates into improved outcome”(James et al 2004) • “coordination of care studies suggest that increased use of formal child mental health treatment does not translate into fewer behavioural or emotional difficulties” (Bickman et al 1995, 1997, 2000) • Often improve without treatment anyway(Burns et al 2004; Lambert et al 2004)

47. Why? • Untested treatments with questionable effectiveness • Treatment programs based on dialectical-behaviour therapy, cognitive-behavioural, cognitive-analytical have yet to be evaluated on their specificity and effectiveness (Chanen et al 2008 James et al 2008) • Poor client engagement • Lax intervention fidelity

48. Health assessments – Necessary but Insufficient • Do health assessments need to occur earlier in a child’s child protection trajectory? • Children placed in care before the age of 7 months had fewer attachment and behaviour problems than those placed later (Tarren- Sweeney 2008) • Children placed late may find it difficult to form secure attachments (Rushton et al 2003) • Is it possible to identify children at risk of chronic maltreatment so that they can be placed in care earlier? • “The challenges are correctly identifying this group so that children are not wrongly separated from their biological parents and predicting which parents are capable of making substantial improvement in their care-giving” (RANZCP 2008)

49. Need for whole of government responses • No single agency can meet the needs of children in OOHC • Coordinated interagency commissioning, planning and service delivery are required – requires committed management • Agreed care pathways and protocols are needed • Multimodal programs integrated with existing service systems that address children’s safety and basic needs, quality of care, carers’ skills and children’s emotional needs • Training and consultative activities for front-line staff • Specialised service within mainstream teams could help develop skills and expertise eg Redbank House(Vostanis, 2010, Chambers et al 2010,Golding 2010)

50. Need for managers to be committed “A commitment to making integrated services and teams work requires a management structure that is prepared to give time to team and service development as well as ensuring that team members are getting the job done. Time is needed for building a team identity, shared vision and ethos and for reflection and the building of relationships. It is easy to give such tasks a lower priority in the face of high need, but ultimately without this, misunderstanding, and miscommunication will weaken service delivery.” (Golding 2010)